Atrial Fibrillation - Surgical and Nonsurgical Advances
Monday Apr 13, 2009, 12:00PM - 01:00PM (EST)
Cleveland Clinic
Cardiac Electrophysiology and Pacing, Cleveland, OH
Cleveland Clinic cardiovascular specialists are at the forefront of development and utilization of the newest therapies for treating atrial fibrillation (AF), the most common of all irregular heart rhythms. At the Center for Atrial Fibrillation, one of the nation's busiest AF programs, our staff provides a full array of approaches to diagnose and treat atrial fibrillation, whether medical, catheter based, or surgical. Please join us to chat with Dr. Bruce Lindsay as he takes your questions about the causes and new treatment options for atrial fibrillation.<br><br>
Dr. Bruce D. Lindsay is Section Head, Cardiac Electrophysiology and Pacing at the Cleveland Clinic Sydell and Arnold Miller Family Heart & Vascular Institute. He is board-certified in Internal Medicine, Cardiology, and Clinical Cardiac Electrophysiology.He served as President of the Heart Rhythm Society 2007-2008 and chaired the Heart Rhythm Society's Annual Scientific Program in Boston in 2006, which was attended by more than 13,000 international physicians, scientists, and allied health professionals. Dr. Lindsay recently completed a term on Board of Trustees for the American College of Cardiology, and formerly chaired the College's Board of Governors. He also serves on the ABIM test writing committee for Clinical Cardiac Electrophysiology
kat4:
A previous questioner mentioned going to the ER after 48 hours in a-fib. I had thought the deadline was 24 hours?
Bruce D. Lindsay, MD:
The recommendation is 24-48 hours, but it is not that specific. In some cases I would be willing to wait 72 hours.
Bruce D. Lindsay, MD:
I would be more concerned about patients who do not tolerate atrial fibrillation, who have a rapid rate, or those who are at increased risk for stroke.
Bruce D. Lindsay, MD:
Risk factors for stroke include coronary artery disease, valvular disease, heart failure, hypertension, age > 65, diabetes, and a prior history of stroke. Most patients with these risk factors take warfarin, so the risk of stroke would not be great if the dose is in the therapeutic range.
TraynFab4:
Hello. I'm a 40 year old healthy male and had a single episode of lone a-fib over a year ago. My BP has been creeping higher over the years (now consistently around 140/80) and my doc is considering putting me on a beta blocker to bring it down. My normal resting HR is about 60-65 and I understand that beta blockers lower HR. Would a beta blocker be a good choice or is there another med that might be better? Thanks again...
Bruce D. Lindsay, MD:
A beta blocker is a reasonable choice. It is largely a matter of trying it to see how you tolerate the medicine. If your heart rate gets too slow your doctor can stop it and try another medication.
bcat:
I'm not sure what is considered a well-controlled heart rate. When I'm not doing much, it stays around 70-85, but even walking sends it way up. It can go as high as 130-150 or more, but I also have COPD caused by methotrexate (for rheumatoid arthritis) and can't exercise much anyway. Would an AV node ablation help the shortness of breath? Thank you.
Bruce D. Lindsay, MD:
n event monitor might help to determine whether your shortness of breath is related to the heart rate. If a rapid rate is the cause of your symptoms and it cannot be controlled by medications, then you might benefit from an AV node ablation.
bcat:
Sorry to be so complicated (and confused)--I also have Barrett's esophagus. Could that be related?
Bruce D. Lindsay, MD:
Sometimes esophageal irritation seems to provoke atrial fibrillation. It is not the primary cause, but it is possible that it contributes to the problem.
Bilbo1933:
My EP told me that a new amiodernone without the side effects of amioderone. What do you know about it?
Bruce D. Lindsay, MD:
He is referring to dronedreone. The physician panel recommended that the FDA approve it and we await their final decision.
Bruce D. Lindsay, MD:
Despite some hype in the press, the reality is that the long term effectiveness of dronederone is probably in the range of 35%. It will be useful, but it is not a panacea.
star26:
My 14 yr old son has dilated cardiomyopathy all chambers. I resuscitated him 4 yr ago - I am dr - but cardiologists did not believe me. Then he's had more bad collapses where he looks dead and no breathing or pulse for over 40 seconds and takes 4 hrs to be able to sit up and talk properly - is pale on oxygen until then. Had reveal inserted only 2 mths ago. My son will be told today by cardiologist they do not know how long he will live. Maybe ARVD maybe connective tissue. May do heart biopsy or transplant Any ideas please?
Bruce D. Lindsay, MD:
It is difficult to comment without knowing all the facts. The results from the insertable loop recorded are important. My opinion is that patients with severe cardiomyopathy and unexplained syncope should be considered for an ICD.
star26:
Can extreme sinus arrhythmia sometimes mean or lead to something serious? My son now has bad collapses but used to just have extreme sinus arrhythmia - but I found his heart went faster and slower even when continually blowing or whistling while on ECG.
Bruce D. Lindsay, MD:
Sinus arrhythmia is normal. I cannot comment on the cause of his collapse without more information.
fattie515394:
I have had 3 episodes of a-fib but have been free of them for over a year. I have been taking sotalol with a dosage of 120mg twice daily and Diovan. Since the a-fib is no longer an issue, I would like to return to Nadolol instead of the sotalol since I can take Nadolol once per day instead of twice. Would you recommend me asking my cardiologist to give this a try? I am a 61 year old male with hypertension.
Bruce D. Lindsay, MD:
It is likely that the atrial fibrillation will recur if you stop the sotalol, so I do not recommend it.
bama jane:
I have had atrial arrhythmia problems for 10 years paroxysmal atrial tachycardia, PAC's daily in different forms-pairs, couplets, trigeminy, bigeminy, wandering pace maker sinus arrhythmia, junctional rhythm, accelerated junctional rhythm. I have 100's daily of these and am very symptomatic. Can tracings from holter and event monitors tell if these extra beats are coming from the same spot? Are PAC's ablatable? How many a day can damage your heart? My father had SVT that turned into a-fib after developing COPD, then developed heart failure from chronic COPD then died. Is a-fib hereditary? If so can I change that?
Bruce D. Lindsay, MD:
Sometimes Holters and event monitors can distinguish differences in origin, but they often not provide enough detail.
Bruce D. Lindsay, MD:
PACs can be ablated. It is unlikely that PACs will cause any damage to your heart. The main reason to consider ablating them is to alleviate your symptoms.
Bruce D. Lindsay, MD:
Some genes have been associated with atrial fibrillation, but the relationship is complex and does not have any direct clinical implications yet.
dsennet:
Does it make sense to postpone an a-fib ablation as long as possible in hopes that techniques will improve OR is my best chance of success with ablation now since I have only had a-fib for about a year? I always self convert and I am on 100X2 flecanide.
Bruce D. Lindsay, MD:
There is no urgency to undergo an ablation. The technology continues to improve. On the other hand, there is evidence that the more you have atrial fibrillation the more episodes you are likely to experience.
Bruce D. Lindsay, MD:
It appears that atrial fibrillation begets atrial fibrillation. I would consider an ablation procedure if the episodes start occurring more frequently or last longer.
feelingood:
Hello, I am 50 years old female; I had a MI at age 40. I went into fibrillation when I had the MI. I have CHF. I have not had any pain or went into fibrillation since the MI. I walk regularly and feel good. My EF is 32 and my Qwave is .0014 (not sure about that number). My cardiologist wants me to have a ICD. I really don't want it but I really want to live as long as possible. Isn't there something else I can do to improve my EF? Is it OK to wait until my EF is at 30? What can I do to improve my risk against going into defibrillation?
Bruce D. Lindsay, MD:
The ejection fraction is our best way to estimate the risk of a life-threatening ventricular arrhythmia. The risk increases as the ejection fraction drops below 40%.
Bruce D. Lindsay, MD:
Current guidelines recommend an ICD if the ejection fraction is less than 35%. The accuracy of the measurement is about 5%, which means that your ejection fraction may be in the range of 27-37%. There is no point in waiting for a value of 30% because the difference between 30 and 32 is not significant.
Bruce D. Lindsay, MD:
Your exercise capacity is another factor that your cardiologist would take into consideration. Approximately 1 in 12 patients who have an ICD implanted for prevention of sudden death will actually be saved by the ICD. Nothing happens in the other 11 patients.
Bruce D. Lindsay, MD:
The problem is that we cannot predict more accurately which patient will have the cardiac arrest. Survival is only 5% if you have a cardiac arrest out on the street and do not have an ICD.
Bruce D. Lindsay, MD:
Based on guidelines derived from clinical studies and approved by a consensus of experts, I think you would meet the criteria for an ICD and should have one implanted. There are medications such as beta-blockers and ACE-inhibitors that help to improve the EF and they have some effect on the risk of sudden death, but unfortunately, medications alone do not provide enough protection.
